Real World Health Care Blog

Tag Archives: ACA

ACA Update: When Medical Insurance Doesn’t Result in Medical Care

Amid continuing partisan debate on Capitol Hill about the Affordable Care Act, the facts are clear: the law has significantly reduced the number of uninsured Americans. Last week the federal government issued a report indicating more than 16 million people who did not have health insurance before have gained coverage thanks to the ACA. According to the Department of Health and Human Services, these gains have delivered the largest drop in the uninsured rate in four decades, bringing that rate down to 13.2 percent.

Linda Barlow

Linda Barlow

“These numbers prove the Affordable Care Act is working, and families, businesses and taxpayers are better off as a result,” said HHS secretary Sylvia Burwell.

While few would dispute that having medical coverage is better than not having medical coverage, coverage is not always a panacea for all ills. First, consumers need to take advantage of the coverage they now have. The federal government recognizes the gap between having medical insurance and getting medical care and has established a website to help consumers use their new marketplace coverage.

For about 19 percent of privately insured adults, higher cost-sharing responsibilities are to blame for the lack of medical care received. Fortunately, the number of Americans reporting they did not receive needed health care because of its cost dropped for the first time last year since 2003, falling from 80 million in 2012 to 64 million in 2014. Still, twenty-one percent of adults with health insurance spent 5 percent or more of their income on out-of-pocket health care costs during 2014, and 13 percent spent 10 percent or more, according to a report from the Commonwealth Fund.

These underinsured Americans face tough choices every month: Do they use their limited funds to pay for needed health care visits, therapies and procedures, or do they use that money for essentials like rent, utilities, child care and food?

Our sponsor, the HealthWell Foundation, believes that no American should go without essential medications and other therapies because they cannot afford them. The Foundation has helped more than 200,000 underinsured patients afford their medical treatments since its launch in 2004. As we recognize the fifth anniversary of the passing of the ACA, we want to know if you agree. Has the ACA helped you and your loved ones receive needed care, or are high out-of-pocket costs still keeping you from seeking the care you need? Let us know in the comments.

President Obama Urges “Millenials” to Sign up for Coverage under Affordable Care Act

In recent days the Obama Administration has been intensifying outreach efforts to increase the number of young people who enroll for insurance coverage under the Affordable Care Act (ACA) before the March 31, 2014 deadline.

Paul DeMiglio

Paul DeMiglio

During a speech in Boston on Oct. 30, President Obama pushed back against criticism of ACA – which he signed into law in March 2010 – by seeking to draw parallels to the Massachusetts’ health care insurance law (“Romneycare”) that then-Governor Mitt Romney signed into law four years earlier.

“And if it was hard doing it just in one state, it’s harder to do it in all 50 states, especially when the governors of a bunch of states and half of the Congress aren’t trying to help. Yes, it’s hard, but it’s worth it. It is the right thing to do, and we are going to keep moving forward. We are going to keep working to improve the law, just like you did here in Massachusetts.”

Governor Romney, on the other hand, rejected the comparison, describing the “Obamacare” rollout as a “frustrating embarrassment” that has failed to learn “the lessons of Massachusetts’ health care.”

However, the two laws did face similar challenges at the start of their implementation, especially among young people. Romneycare saw an extremely low registration rate among younger demographics until the deadline. Likewise – although the White House set a goal of getting 2.7 million 18-34 year olds signed up through HealthCare.gov by the end of March – a recent study by the Commonwealth Fund revealed that only one in five people who visited the federal or state enrollment sites were 18-29.

A Dec. 4 article in The New York Times makes the case that many young people are likely to follow enrollment patterns that were similar to those in Massachusetts in 2006 – by pushing it off until the deadline hits.

“The experience of Massachusetts under Gov. Mitt Romney showed that most people, especially young people, acted only when they approached a deadline,” write Jonathan Weisman and Michael Shear, “and with the federal law, the deadline to have insurance or pay a penalty is months away.”

According to an Oct. 30 article in Business Insider, two former Massachusetts officials who played major roles in creating and rolling out the Massachusetts health law — Jonathan Gruber and Jon Kingsdale – say successful implementation of massive health care changes can come slowly at first:

“In Massachusetts, the officials said, only .03% of the share of Massachusetts residents who eventually enrolled for health insurance signed up in the first month the law went into effect. In the final month of enrollment, before the mandate to purchase insurance kicked in, more than 20% of the final tally signed up.”

Last week President Obama renewed strategies to increase enrollment rates by actively engaging young people, who are widely seen as critical to the financial stability of Obamacare. Addressing 160 participants from across the country at the Dec. 4 Youth Summit, the President urged “Millenials” – including DJs, entrepreneurs and organizational heads – to talk up Obamacare and get their peers to sign up on HealthCare.gov.

The Washington Post is reporting signs that enrollment among younger Americans is beginning to pick up, with a three-day total of about 56,000 from Dec. 1-3 – more than twice the number of online signups on HealthCare.gov during the entire month of October.

Now tell us what you think. Can Romneycare serve as an effective model for implementation of Obamacare, especially with respect to generating more signups among younger population demographics? What, if any, provisions from that law are applicable to rolling out the ACA? Have you tried to enroll on HealthCare.gov and were you successful?

Categories: Access to Care

Not Your Mother’s Big Pharma

In a September 29 article in Adweek, Joan Voight demonstrates how the Affordable Care Act (ACA) is expected to create new opportunities for pharmaceutical stakeholders to play a more active, personalized role in managing patient care through interactive web-based tools. Three aspects of the ACA will change the way treatment decisions are made and reinvent how patients and Big Pharma interact.

Paul DeMiglio

Paul DeMiglio

Fill the Primary Care Gap
Although providers will be overwhelmed by an expected uptick in newly insured patients, pharmaceutical companies can help reduce the strain while strengthening relationships with consumers in the process. MerckEngage — an online educational and marketing program that has attracted 8.2 million visits since its launch in 2010 — is one example of just how this can play out. Among some of the resources the website gives members access to include:

  • Free personal health tracking
  • Daily planners
  • Food and exercise tips
  • E-mail messages
  • Content updates

Doctors who sign up will receive alerts to track their patients’ activity, and starting this year the program also features mobile versions for patients and providers alike.

Provide Solutions to Adherence Challenges
A key goal of the ACA — to prevent sick patients from developing more serious conditions and needing more care — emphasizes the importance of increasing medication adherence. This need presents a valuable opportunity for pharma to personalize treatment and communicate in ways that resonate effectively with target audiences.

AstraZeneca is collaborating with Exco InTouch to help patients and doctors track and manage chronic conditions through mobile and web-based tools:

“The first app addresses chronic obstructive pulmonary disease. Patients enrolled in the program collect, transmit and review their own clinical data, while their doctors use real-time information to personalize each patient’s care, adjust meds and possibly prevent hospitalization. The patients’ identifiable data is only seen by patients themselves and their healthcare providers, says AstraZeneca,” the report notes.

Develop Innovative Bundles
Implementation of ACA will also change the way prescriptions are made, with insurance companies and accountable care organizations (ACOs) choosing what to prescribe instead of individual doctors. This can serve as an opportunity for pharma to build support among ACOs by creating and branding a package of services for patients and providers that spans behavior modification, education, tracking and dispensing of drugs.

Eli Lilly’s online diabetes program that helps patients and families manage the disease, Lilly Diabetes, was critical to paving the way for this marketing approach, according to the article:

“In Lilly’s case the tools include a meal planner, a self-care diary, a carbohydrate tabulator and even an emergency guide in case of hurricanes or earthquakes.”

Now we want to hear from you. Do you agree with the article? What are the long-term implications of pharmaceutical companies having access to more data about consumers in this new era of digital outreach? What might be the potential advantages and disadvantages?

(Medical) Home is Where the Care and Cost-Savings Are

The word “home” has many connotations: the building in which you live, the place you come from, and even the end point of a game. Now, there is a new type of home: The Patient-Centered Medical Home (PCMH).

Linda Barlow

Linda Barlow

PCMH is a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety. It has become a widely accepted – and cost-effective – model for how primary care should be organized and delivered, encouraging providers to give patients the right care in the right place, at the right time and in the manner that best suits their needs.

“The magnitude of savings depends on a range of factors, including program design, enrollment, payer, target population, and implementation phase,” explains Michelle Shaljian, MPA, Chief Strategy Officer of the Patient-Centered Primary Care Collaborative (PCPCC). “Most often, the medical home’s effect on lowering costs is attributed to reducing expensive, unnecessary hospital and emergency department utilization.”

When the Affordable Care Act (ACA) was signed into law in 2010, medical homes got a boost because of numerous provisions that increased primary care payments, expanded insurance coverage and invested in medical home pilots, among other programs.

The model has been adopted by more than 90 health plans, dozens of employers, 43 state Medicaid programs, numerous federal agencies, hundreds of safety net clinics and thousands of small and large clinical practices nationwide since then. Among the results:

  • In Michigan, Blue Cross Blue Shield – the nation’s largest PCMH designation program — saved an estimated $155 million in preventative claim costs over the first three years of implementation.
  • CareFirst Blue Cross Blue Shield in Maryland reported nearly $40 million savings in 2011 and a 4.2 percent average reduction in expected patient’s overall health care costs among 60 percent of practices participating for six or more months.
  • In New York, the Priority Community Healthcare Center Medicaid Program in Chemung County saved about $150,000 or 11 percent in the first nine months of implementation, reduced hospital spending by 27 percent and reduced ER spending by 35 percent.
  • In Pennsylvania, Pinnacle Health achieved a zero percent hospital readmission rate for PCMH patients versus a 10-20 percent readmission rate for non-PCMH patients.

The PCPCC is the leading national coalition dedicated to advancing PCMH. According to PCPCC, the medical home is an approach to the delivery of primary care that is:

  • Patient-centered: A partnership among practitioners, patients and their families ensures that decisions respect patients’ wants, needs and preference, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: A team of care providers is accountable for a patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients access services with shorter wait times, “after hours” care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

According to Melinda Abrams, Vice President of Patient-Centered Primary Care Program at the Commonwealth Fund, to have the greatest impact, a medical home must be located at the center of a “medical neighborhood” inhabited by hospitals, specialty physicians, physical therapists, social workers, long-term care facilities, mental health professionals and other service providers. She notes that it is the role of the primary care provider to coordinate care and make sure that patients don’t slip through the cracks, or receive tests or procedures they’ve already had – a particular concern for patients who see multiple doctors.

The National Committee for Quality Assurance (NCQA) – a non-profit, independent group dedicated to improving health care quality – accredits and certifies a wide range of health care organizations and is the leading national group that recognizes PCMH with the most widely adopted model. Currently, there are almost 5,000 NCQA Recognized PCMHs across the country.

Other organizations with PCMH recognition programs include Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), the Joint Commission, and URACVideos from the American Association of Family Physicians (AAFP) feature family physicians who discuss practice redesign aimed at lowering costs, maximizing staff expertise and improving patient care.

“Practices seeking to initiate a patient-centered medical home will find that an assessment process is very helpful to understand where they are,” said Shaljian. “Some practices have electronic health records, a very strong history of team-based care, and strong connections with specialists, hospitals, and other stakeholders in the community, while others do not. Some are deeply affected by an internal culture of quality improvement, which makes a huge difference in how successful some medical homes are.”

Want to learn more about PCMH? Visit the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality content-rich Resource Center.

How can health care continue to move the nation to PCMH? And how can the model tackle its number-one challenge: the current fee-for-service payment system?